A Private Payer Persective

OBJECTIVE
To present the issues, concerns, and advances possible as private (commercial) payers attempt to incorporate value into their health care plans, using a commercial provider of disease and medication management as a model.


SUMMARY
Most approaches to health care have dealt with persistent or chronic diseases, but, increasingly, payers are expanding their interests to include wellness, high-risk case management, and care management. Technology is crucial in health care today, enabling clinicians to reach out to patients, capture data, and integrate medical and pharmaceutical data. Data integration will help build efficiencies and effective ways to deal with the growing population of patients who have chronic disease. The disease-centric model is being replaced with a patient-centric model. Health care providers must help patients identify their unique motivators and de-motivators and encourage them to be self-sufficient partners in their own health care.


CONCLUSION
Adding value to traditional health care is a task that seems daunting at first. It is not insurmountable, however, and ultimately, adding value decreases cost in unprecedented ways.

H ow do payers and our customers really view value? This discussion addresses value from a different perspective, that of a provider of care management services with a commercial perspective. It attempts to predict what the future holds and describe disease management' s DM' s value and opportunities, using a large DM and care enhancement company' s experience as a case study.
Healthways was established 25 years ago. Initially, it began as Diabetes Treatment Centers of America, and after establishing proficiency in diabetes, Healthways expanded into other disease states. It remains the largest full-service disease management company in the United States, covering 50 million lives and engaging 2 million active participants. Working primarily with health plans, Healthways provides services to about 600 administrative-services-only (ASO) clients. Recently, Healthways expanded into the international arena. The company welcomes external review, collaborates extensively with third parties, is working with the Centers for Medicare & Medicaid Services (CMS) on a chronic care pilot, and emphasizes evidence-based practice. Figure 1 describes the care spectrum. Most of the Healthways work has been concentrated toward the right-hand side of the spectrum-in the persistent or chronic diseases and DM spacebut, increasingly, the company has expanded into wellness and high-risk case management/care management. Integration has already begun and will continue to evolve to build efficiencies and effective ways to deal with the growing population of patients who have chronic disease.
Technology is crucial in health care today, enabling clinicians to reach out to patients, capture data, and integrate medical and pharmaceutical data. The Healthways system captures and tracks information such as National Drug Codes (NDCs) and medical claims data. Extensive real-time information from patients is also collected. Certain patients, who have heart failure, for example, are provided with scales and blood pressure monitoring equipment that are connected to the system. Daily weights and blood pressures are transmitted electronically to clinicians, allowing immediate treatment adjustments or interventions. This comprehensive data collection system also facilitates reporting.
The search for value in health care is accelerating and will continue. Its dimensions are expanding; DM has subtly evolved into care management because patients seldom present with a single disease. The disease-centric model is being replaced with a patient-centric model, so patients who enter a diabetes program will also receive coordinated care for their comorbidities such as heart failure or depression.  Author health plans' non-DM population, whether up or down, will be used as a proxy for the trend the DM population would have experienced absent the DM program. This adjusts for any substantive benefit changes or major cost-control measures the health plan may have instituted during the same period. Another aspect of total cost is examining all line items that contribute to total cost and making a determination of where the savings actually occurred. Common line items include inpatient stays, outpatient services, physician office visits, pharmacy charges, emergency department visits, and laboratory costs. It is possible and, in fact, likely that pharmaceutical costs may increase due to improved adherence, but reductions in hospitalization, home health care visits, or other line items may lead to an overall decrease in total cost. Note that this example ignores productivity gains, which we know are occurring but are often difficult to capture.
Doing nothing can sometimes look like doing something because of "regression to the mean"something we try to avoid. To control for regression to the mean, the entire population must be examined, not just the high-cost group in isolation. Regression to the mean is a statistical principle related to how costs associated with individuals move within a population. Some individuals experiencing current high utilization (cost) will have lower costs in a subsequent period. Others experiencing current low costs will have higher costs in a subsequent period. Therefore these subgroups are "regressing," or moving toward a mean or average cost for the group as a whole.
Also, to avoid double counting when data are collected for the total population, diseases are assigned a place in a hierarchy .

I II I T Th he e H He ea al lt th hw wa ay ys s C CM MS S P Pi il lo ot t
Healthways is currently participating in 2 CMS Medicare Health Support pilot programs that also incorporate key components of medication therapy management. The enrolled population is approximately 43,000, with an average age of 75 years. The population is equally distributed on the basis of gender, and approximately 30% of the group is older than 80 years. Greater than 70% have 5 or more coded comorbidities, and the average number of prescription drugs is 10. When over-thecounter medications and other nonprescription drugs (self-reported by patients) are included, that number increases to more than 14.
In this group, annual mortality is 15% to 18%, a cost concern because health costs tend to be greatest in the last 3 to 6 months of life. Healthways knew that adherence to standards of care (SOC) is an important issue. Our review identified good adherence to certain SOC. Patients in this population tended to have appropriately controlled HbA1c (glycosylated hemoglobin) and lipid levels, have received preventive care, and have good blood pressure control if they had heart failure. On other fronts, however, adherence was poor: blood pressure control in diabetics, end-oflife care, and use of pharmaceuticals all had ample room for improvement. In addition, the prevalence of depression, cognitive decline, social isolation, poor health care literacy, and safety concerns were high, representing a challenge. The CMS population differed from the Healthways commercial populations in several ways. They were at high risk for hospitaliza- tion and were often institutionalized or needed greater provisions for hospice or palliative care. They also needed intensive case management, and that precipitated a need for outreach workers. Healthways looked at the population' s metrics and built a plan that was more robust in unique ways than that typically employed in a commercial population to address the special needs of this older demographic. Table 1 describes the 4 Healthways tenets and the reasons why they were established. To date, Healthways considers itself in a learning mode, having encountered some surprises over the course of this study. For instance, the patients in these programs have been more accessible than anticipated. Their propensity toward social isolation, perhaps, has, in some ways, been an advantage, making them more willing to interact with and talk with our clinicians. They are easily engaged and receptive to contact, with more than 95% agreeing to contact either by phone or in person. Depression has been a greater challenge than anticipated, with 24% of the population meeting the diagnostic criteria. This population also has significant medication issues. However, the care coordination issues we anticipated failed to materialize, and physician collaboration has exceeded our expectation. Healthways has included physicians in the program development process in several ways, including physician advisory councils.
Some concerns related to cost management have developed. To avoid loss of value, Healthways is proceeding cautiously to ensure that some services do not fall through the cracks. In the past, health care in the United States has lacked the incentives necessary for optimal patient care. A good way to describe it is to say that those who have done more have been paid more. Physicians, for example, are paid by Current Procedural Terminology codes, so the more procedures completed, the more they were (and are) paid. The right incentives must propel clinicians and decision makers toward where the payers want and need health care to go. The system needs new and better-aligned financial incentives. Disease or care management provides value by establishing a framework. When providers work within a framework that aligns incentives, they should be rewarded.
In the future, reimbursement must increasingly be based on performance and outcomes to address gaps in care (see Table 2 for an example of gaps in cancer treatment). Best performance (outcomes) will require collaboration among all stakeholders in the heath care process. Some processes must be reengineered, meaning restructured in novel ways to improve efficiency. Along these lines, Healthways has been asked and is now participating in a few pay-for-performance programs through health plans.
Members (or patients) have a responsibility to be involved in this change, not only as the targets of cost shifting but also as full-fledged health care team members. Health care teams should focus on behavior changes to reduce risk factors. Maximizing the patient' s effectiveness on the team requires several steps. Ample information must be available to the patient, and patients need education about their pattern of health care consumption and its effectiveness. Health care providers also need to help patients gain insight into the discrepancy between their health needs and wants and help them become independent and informed in their choices. Resolving needs and wants discrepancies often occurs via a motivational interview process that leads the member to the point that they want to change. It goes beyond providing information, or creating lifestyle awareness. It is really about motivating the individual to weigh the pros and cons and make suitable choices and mapping the steps they will take to achieve their goals. Self efficacy occurs when clinicians give patients the tools and confidence to succeed.

I II I C Co on nc cl lu us si io on n
Adding value to traditional health care is a task that seems daunting at first. It is not insurmountable, however, and ultimately, adding value decreases costs in unprecedented ways.

DISCLOSURES
This article is based on the proceedings of a symposium held on April 5, 2006, at the Academy of Managed Care Pharmacy' s 18th Annual Meeting and Showcase in Seattle, Washington, which was supported by an educational grant from sanofi-aventis and sponsored by the Benefit Design Institute. The author received an honorarium from sanofi-aventis for participation in the symposium. He is employed by Healthways, Inc., the subject of his article.  Poor communication 4